Filling the Gaps Providing Palliative Services

& End of Life Care

Serena Rix, Pharm D

07 February 2017

Nothing to Declare

Introduction Recent evidence suggests patients, with life-limiting

illnesses wish to remain at home for as long as possible & government supports this care model.

Many Health Care Professionals (HCPs) as well as co-operative family members are needed to provide this care

We decided to investigate what the knowledge gaps are for community pharmacists, in this situation, and suggest ways to help bridge them.

2-part study:

Characterization of Rx for patients discharges from Grey Nuns Tertiary Palliative Care Unit (TPCU).

Survey of community pharmacists to determine their knowledge of medications used in palliative care & perceived barriers to provision of services to these patients in the community.

TPCU, Grey Nuns Hospital 20 beds for patients

with complex issues

Pain & symptoms

Psychosocial

~ 200-250 admissions

per year

75-80% die on the unit

Others discharged

home or to other

facilities

Discharge Rx Study

Ethics approval

obtained

Prescription records

(2009-2014) for the

patients who had

pharmacist involvement

at discharge were

examined (n=75)

Typical discharge Rx

characterized

Discharge by Cancer Type

No non-cancer patients were

represented in the data

(not excluded)

Breast

[CATEGORY NAME]

Genito-urinary

Gynecology

Head and Neck

Hematology

Lung

Muscoloskeletal

PRUNK

Discharge Data Year 2009

(5)

2010

(12)

2011

(20)

2012

(10)

2013

(12)

2014

(16)

Total

# Pts admitted 245 241 250 219 200 195 1350

# Pts Home 40 16.3% 42 17.4% 39 15.6% 30 13.7

%

24 12% 20 10.2% 195 14.4%

# Records 5 12.5% 12 28.6% 20 51.3% 10 33.3

%

12 50% 16 80% 75 38.5%

Male 1 20% 7 58.3% 10 50% 4 40% 6 50% 4 25% 32 42.7

Mean Age

(range) 53.2 31-70 66.2 30-85 55.1 34-70 55.9 38-81 58.8 46-81 60.4 48.85 58.2 30-85

Mean LOS

(range) 22.8 10-35 25.1 9-72 26.4 4-160 25.3 5-81 36.6 8-142 17.6 3-38 25.6 3-160

Mean Regular

Rx 8.6 6-13 7.2 5-11 7.5 4-16 8.7 5-14 7.3 5-10 7.1 4-13 7.8 4-16

Mean prn Rx 3.4 1-5 2.5 1-5 3.1 2-6 2.6 1-5 2.8 1-6 2.7 1-4 2.7 1-6

• Increasing pharmacist involvement with discharge over the

years promoting seamless care (intentional goal)

• Fewer calls from community pharmacy to physicians for

clarification with pharmacist participation (anecdotal)

• 7-8 regular medications and 2-3 prn medications per patient on

discharge

• Earlier in disease trajectory (not end-of-life)

Palliative Care Essential Medications

Standard (most patients)

Analgesics

+/- adjuvants

Laxatives

Antiemetics

Anxiolytics

Frequent (as indicated)

Steroids

PPI/antacids

Antidepressants/stimulants

Study: Regular Rx Represented

0

10

20

30

40

50

60

70

80

2009 (n5) 2010 (n12) 2011 (n20) 2012 (10) 2013 (12) 2104 (n16)

Study: PRN Meds Represented

0

10

20

30

40

50

60

70

80

0pioid Laxatives Adjuvants Anti-emetics Antacids Anxiolytics Hypnotics

2009 2010 2011 2012 2013 2014

Opioids (Regular)

0

5

10

15

20

25

30

35

40

Morphine Hydromorphone Oxycodone Methadone NONE

2009 (5) 2010 (12) 2011 (20) 2012 (10) 2013 (12) 2014 (16)

Prn & regular charts almost identical: regular & prn use of same opioid

Opioids are the analgesics of choice in this population

Methadone most common: admission for methadone rotation

MEDD MEDD for regular opioids

calculated using conversion app “Opioids”

MEDD range 12.5 -11,025mg/day

Colleges need to reconsider capping opioid doses/ limiting dosage forms in this population

Consider remuneration for pharmacies to provide improved control over distribution

Patients should NOT die in pain

Follow-up Research Pharmaco-economic

study to examine cost

impact of limiting

opioids supplied

Cost to payers of

pharmacists increasing

pharmaco- vigilence

with opioids

Propose tighter controls

for distribution to deter

diversion

Laxatives Laxatives (Regular) Laxatives (Prn)

0

10

20

30

40

50

60

2009 (5) 2010 (12) 2011 (20)

2012 (10) 2013 (12) 2014 (16)

0

1

2

3

4

5

6

7

8

2009 (5) 2010 (12) 2011 (20)

2012 (10) 2013 (12) 2014 (16)

• Patients on opioids generally require laxatives

• Increased use of PEG seen, when introduced on DBL (Palliative BC)

• Enemas & other nursing interventions not listed

Anxiolytics Regular Prn

0

2

4

6

8

10

12

14

16

2009 (5) 2010 (12) 2011 (20) 2012 (10) 2013 (12) 2014 (16)

0

5

10

15

20

25

30

35

40

2009 (5) 2010 (12) 2011 (20) 2012 (10) 2013 (12) 2014 (16)

Benzodiazepines are not the drugs of choice in this population

Off-label use of anti-psychotics

Antiemetics Regular Prn

0

2

4

6

8

10

12

14

16

18

20

2009 (5) 2010 (12) 2011 (20) 2012 (10) 2013 (12) 2014 (16)

0

5

10

15

20

25

30

35

40

45

2009 (5) 2010 (12) 2011 (20) 2012 (10) 2013 (12) 2014 (16)

• Haloperidol use is off-label

• Domperidone use decreasing: QT interval

TPCU: Typical Discharge Rx Dr Will B. Better

1234 Feelgood Drive

Wellsprings, Alberta

T0A 1A0

(587) 987-6543

7 February, 2017

Ima Ailing, 789 Aiken Road, Payne. AB. T0Z 1Z0

1. Methadone 50 mg po q8h

2. Methadone 15 mg po q1h prn pain

3. Olanzapine 2.5 mg po q8h

4. Olanzapine 2.5 mg po q1h prn anxiety/nausea

(May use orally dissolving tablets per pt. preference)

5. PEG 17g po bid

6. Bisacodyl 10 mg PR q3days prn

7. Duloxetine 60 mg po daily

8. Pantoprazole 40 mg po daily

9. Dexamethasone 4mg po daily

Will. B. Better

Implications

This provides information regarding medications seen at discharge, so we can provide suitable education to the community pharmacists regarding dosing and other issues specific to palliative care.

The Survey A survey inviting community pharmacists to offer

opinions on this matter was distributed electronically

via the Alberta College of Pharmacists and Alberta

Pharmacists Association.

8 questions (some multi-part) and free text

opportunities were provided to determine

pharmacists comfort levels and perceived barriers to

provide services to palliative patients.

47 surveys were returned of which 42 were complete

Free text comments were categorized onto themes

Demographics

Rural Small Urban Urban

Years in Practice

0

2

4

6

8

10

12

14

0 to 5 6 to 10 10 to 20 21 to 30 31 to 40 41-50 > 50

Location of Practice

Palliative Education

Received

Number of Palliative Patients Per Year

0

5

10

15

20

25

30

None Self Formal Degree Other(experience)

0

2

4

6

8

10

12

14

16

18

20

Comfort Levels With Palliative Issues

0 5 10 15 20 25 30 35 40 45

Opioids

Monitor/rotation

BTA/Incident

Bowel Care

Dyspnea

Steroids

Neuropathic pain

Neuroleptics

Swallowing

Routes of admin

Appetite

Communications

Psychosocial Issues

Referral services

V Unconfortable Uncomfortable Neutral Comfortable V Comfortable

Barriers to Providing PC in the Community

[CATEGORY NAME]

[PERCENTAGE]

Time 28%

HCP 6%

Financial 11%

Inventory 4%

Equipment 9%

Communications 17%

No Barriers 2%

Attitudes Toward & Types of

Education Preferred

0

5

10

15

20

25

30

Attitude More Ed Seminars Web base Interactive Print Books Website App

not answered Not at all interested Not interested Neutral Interested Very Interested

Conclusions Pharmacists play a vital role in the care of palliative patients

at home & can monitor medication use and efficacy.

Medications regimens may be complex and include unusual doses, indications, & administration routes

There are many perceived and existing barriers to the provision of this care, including implications of USP797.

More palliative care education is required. It has been incorporated into the pharmacy program at the University of Alberta & we are investigating ways to provide educational opportunities to practicing pharmacists including therapeutics & communications.

HCPs must explore ways to improve inter-professional communications to provide optimal care for these patients. Technology may provide solutions.

Thanks to

Covenant Health

Survey participants

Viki Muller, Braiden

Helluc, & Jan Thomson,

staff of TPCU & EZPCP

Patients and their families

You, for your attention &

participation